| Interpretation of Diagnostic Testing for Primary Aldosteronism |
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Eu Jeong Ku |
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Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul National University Hospital Gangnam Center, Seoul National University College of Medicine, Seoul, Korea |
| 일차 알도스테론증 진단 검사의 해석 |
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구유정 |
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서울대학교 의과대학 서울대학교병원 강남센터 내분비대사내과 |
Correspondence:
Eu Jeong Ku, Tel: +82-2-2112-5000, Email: eujeong.ku@snu.ac.kr
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Received: 10 May 2026 • Revised: 11 July 2026 • Accepted: 16 July 2026 |
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| Abstract |
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Primary aldosteronism (PA), the most common cause of endocrine hypertension, is increasingly recognized as a major contributor to cardiovascular and renal morbidity. Despite its high prevalence and the availability of effective, targeted therapies, PA remains substantially underdiagnosed in routine clinical practice. Accurate interpretation of the diagnostic evaluation is therefore critical for facilitating timely recognition, guiding subtype classification, and selecting appropriate treatment. Initial screening relies primarily on the aldosterone-to-renin ratio (ARR); however, the ARR should not be interpreted solely against fixed cutoff values because antihypertensive medications, dietary sodium intake, potassium status, age, and other clinical factors can substantially alter aldosterone and renin concentrations. Contemporary diagnostic approaches therefore emphasize determining whether aldosterone secretion is inappropriately elevated relative to the degree of renin suppression, rather than relying on the ARR as an isolated numerical threshold. The 2025 Endocrine Society guidelines introduced several notable changes, including a recommendation to screen all patients with hypertension, the adoption of lower ARR thresholds, and greater emphasis on probability-based diagnostic decision-making. Confirmatory aldosterone suppression testing is no longer considered universally necessary after a positive screening result; instead, its use should be individualized according to the pretest probability of PA, the likelihood of surgically remediable unilateral disease, and whether the patient is willing and eligible to undergo surgery. For subtype classification, adrenal computed tomography (CT) provides essential anatomical information, including the detection of adrenal masses and assessment of adrenal morphology; however, it cannot reliably establish functional lateralization because CT findings frequently conflict with adrenal venous sampling (AVS) results. AVS therefore remains the reference standard for differentiating unilateral aldosterone excess from bilateral disease, but its diagnostic accuracy depends on technically successful catheterization and careful interpretation of the selectivity and lateralization indices. Emerging functional imaging techniques, including 18F-metomidate positron emission tomography, may provide complementary information or serve as potential alternatives when AVS is unavailable, unsuccessful, or contraindicated; however, their indications, accessibility, and diagnostic performance remain insufficiently established for routine use. This review provides a practical framework for interpreting biochemical screening, confirmatory suppression tests, adrenal imaging, and AVS in patients with suspected PA. It also summarizes recent guideline updates and discusses the clinical and health-system considerations relevant to their implementation in Korea. |
| Key Words:
Hyperaldosteronism; Aldosterone-to-renin ratio; Adrenal venous sampling; Adrenal gland diseases; Hypertension |
| 주제어:
일차 알도스테론증; 알도스테론-레닌 비율; 부신 정맥 채혈; 부신질환; 고혈압 |
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